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  1. Medciare Part D was established as part of the...
    Medicare Prescription Drug Improvement and Modernization Act (MMA) which established voluntary outpatient prescription drug coverage for Medicare beneficiaries.
  2. How do Beneficiaries Receive Coverage?
    • Stand-alone prescription drug plans (PDPs)
    • Medicare Advantage prescription drug plans (MA-PDs)
  3. Stand-alone prescription drug plans (PDPs)
    • receive hc through Medicare Part A&B
    • free standing prescription drug plans (separately serviced)
    • traditional FFS insurance
  4. Medicare Advantage Prescription Drug Plans (MA-PDs)
    • HC received through Medicare Part C and prescription drug coverage
    • managed health care plans (HMO, PPO)
    • prescription plan ins bundled (administered) in their program --> under one umbrella
  5. Why is Medicare trying to control drug costs?
    Increase the number of prescription plans
  6. Who pays the most for Medicare Part D?  Who pays the least?
    • Federal government pays the most for Medicare Part D
    • State pays the least
  7. Standard Benefit of Part D
    everyone typically gets --> it has co-insurance
  8. Enhanced Benefit
    • some plans offer enhanced benefits (alternative benefit designs), but must be comparable in coverage to the standard benefit
    • differences in (partial) deductibles, (higher) premium payments, coverage in the doughnut hole
  9. Part D has formularies and cost saving tools such as:
    • step therapy - encourages use of similar, lower cost drugs
    • prior authorization - use drugs not on formulary
    • quantity limits such as 30 days supply
    • tiered formularies - different copay for brand and generic drugs, and tiers for high cost specialty drugs
  10. Part D appeals can be sought for:
    • non-formulary drugs
    • step therapy requirements
    • prior authorization requirements
    • quantity limits
    • tiered cost sharing issues
    • beneficiaries have a 60 days to appeal if Part D plan doesn't grant a formulary exception
  11. Important Information for Enrollees
    • Voluntary program
    • Medicare Part D is NOT ran by the government or Medicare; run by independent insurance companies who have been approved by Medicare.
    • Part D plans vary from company to company
    • Make sure pharmacy is in the preferred network
    • Look at drug formulary before purchasing drugs
    • Enrollees can only change plans once a year (Oct 15-Dec 7)
  12. Initial Enrollment Period 
    • Total of 7 months:
    • 3 months before 65 + the month you become 65 + 3 months after you're eligible
    • penalty for late enrollment
  13. When marketing Part D, pharmacists CAN provide
    • names of plans they accept
    • help applying for income subsidy
    • distribute marketing materials and compare plans
    • distribute application forms
    • provide objective information on plan formularies, covered benefits, copayments, etc
  14. When marketing Part D, pharmacists CANNOT provide
    • direct, urge, persuade any patient to enroll in a particular plan based on financial interest of pharmacy
    • offer incentives/gifts to enroll in a specific plan
    • health screenings combined with plan marketing is prohibited
    • receive compensation from the plan (direct/indirect)
    • created your own material comparing plans
    • directly recommend a "best choice" for the patient
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